The Gross Distortion of "Scientifically Validated" Mental Health Care
Koreans have a folk saying that translates, "The navel is bigger than the belly." The expression applies when someone loses a proper sense of proportion - for instance, something incidental, or instrumental, becomes so overdone that it overwhelms whatever it's supposed to serve.
In mental health care, our job is to provide care for certain sorts of suffering. The sciences help, or can. When we think of "being scientific" as definitive of our work, the navel is apt to grow bigger than the belly.
Most of us most of the time exaggerate the role and importance of science in mental health care. The leaders of the professions not only indulge but demand such exaggeration, most notably when arguing publicly for more money, greater power, and more prestige for their trades.
Once we believe that our "scientific base" gives us legitimacy and authority, we're apt to believe (and convince the public) that without a scientific base, what we do lacks legitimacy.
That ramps up the urgency with which we claim to be scientific. So we claim to have more science than we have, we claim that it proves things that it does not, we claim that it answers questions that simply are not scientific questions.
And some of us even condemn as "unethical" and dangerous clinicians who do not share our particular - and often peculiar - notions of what counts as good science.
Meanwhile, we overlook the actual sources of our beliefs, we ignore vast intellectual resources we could use to good effect, and we give bad answers with undue confidence.
That is one gigantic navel.
The issue can be illustrated by a controversy raging around the draft version of DSM-V, which makes drastic changes in DSM-IV, purportedly on the basis of science.
Robert Spitzer, editor of DSM-III, and Allen Frances, editor of DSM-IV, have been highly critical of the new edition. When DSM-III was developed, Spitzer and company made a calculated compromise between established clinical practice and more modern notions of scientific investigation. Clinical practice, it was held, had developed a body of beliefs that deserved respect, even if it did not have the modern scientific basis claimed for newer diagnoses. DSM-IV continued this balancing act.
Frances, in particular, makes the argument that where established practice has found a category to be useful, we should relinquish it only if there is scientific evidence that it is wrong. The editors of DSM-V, to the contrary, argue that unless something has a scientific basis, it should be discarded.
Whatever we may think of DSM-III and IV, they illustrate the view I am espousing here: our job is to provide care, and currently fashionable notions of science hardly exhaust our ways of accumulating useful beliefs. DSM-V, on the other hand, makes science (more precisely, its editors' highly debatable contentions about current science) more important than any other form of learning how to provide care.
Maybe tens of thousands of clinicians have treated millions of patients for disorders that do not exist. That's certainly possible. But every study of mental health outcomes has shown that most people who get care get better. That would certainly seem to suggest that care provided without benefit of scientific validation has something to commend it. And that argues that science is not definitive of good care.
We can establish this point by looking at the media's (and APA leadership's) darling method, cognitive behavioral therapy. Cognitive behavioral therapy (CBT), despite its own lofty rhetoric about its "scientific validation," proves that effective care does not depend on good science.
We all know that cognitive behavioral therapy claims to be the most "scientifically validated psychotherapy," on the basis of randomized clinical trials that test for "treatment outcomes." I'll show, in later blogs, that RCT's show considerably less than CBT'ers claim. But there's no disputing that, in many circumstances, cognitive behavioral therapy is an effective way to provide care.
But as a matter of plain fact, the central psychological tenets of CBT - for instance, that thoughts cause emotions, that cognitive distortions cause psychopathology, that minimizing, maximizing, and catastrophizing are pathogenic - are not "scientifically validated."
In fact, very strong sciences maintain, and can reasonably be said to show, that those assertions are simply false.
The overwhelming majority of research in affective neuroscience is done on animals, who clearly lack the neurology for high-level cognitive functions. (Dolphins, whom most people who know them well would claim have emotions, do not even have neocortex.) I do not know any major research program in affective neuroscience, or other sciences that study emotion, that would claim that emotions depend on high-level cognitive functions.
And cognitive distortion is not pathogenic-it is completely normal. Rationality is rare. The work of Kahneman and Tversky (for which Kahneman won the Nobel prize) established beyond doubt that our most common habits of thought are wildly irrational. (Dozens of books have popularized this work in the last few years - for instance, Bozo Sapiens and Predictably Irrational.)
Minimizing and maximizing are basic functions of maintaining a coherent belief system, as psychologists have known since Jerome Bruner's work over fifty years ago.
Catastrophizing is an essential human virtue - shown when we buckle our seat belts, when we stop buying a particular medicine because a miniscule fraction of one percent of its users suffer harm, or when we regulate food safety on the basis of outbreaks of illness that affect less than one one-millionth of Americans.
So if we accept CBT's claim to have shown itself effective, we must also accept that beliefs need not be scientifically validated to provide a basis for effective care, since its beliefs are certainly not scientifically validated.
That does not mean we should be happy with false beliefs - or with systems of psychotherapy that teach patients falsehoods. But it proves pretty well that equating effective care with science is misguided.
Science matters - and a well-proportioned navel can be very attractive. But we really need to think much more carefully about just how science can aid care, and how the insistence that only science can provide useful knowledge warps our thinking and our practice.